Objective: The purpose of this study is to examine the association between verbal learning, fluency, and processing speed with anxious depression symptomatology (ADS) among diverse Hispanics. We hypothesized an inverse association of anxious depression with neurocognition among Hispanics of different heritage. Design: Data are from the Hispanic Community Health Study/Study of Latinos. The sample included 9,311participants aged 45–74 years (mean: 56.5 years). A latent class analysis of items from the Center for Epidemiological Studies for Depression scale and the Spielberger Trait Anxiety Inventory was used to derive an anxious depression construct. Neurocognitive measures included scores on the Brief Spanish English Verbal Learning Test (B-SEVLT, learning and recall trials), Word Fluency (WF), Digit Symbol Substitution (DSS) test, and a Global Cognitive Score (GCS). We fit survey linear regression models to test the associations between anxious depression symptomatology and cognitive function. We tested for effect modification by sex, Hispanic heritage, and age groups. Results: Among men, 71.6% reported low, 23.3% moderate, and 5.1% high ADS. Among women, 55.1% reported low, 33.2% moderate, and 11.8% high ADS. After controlling for age, sex, sociodemographic characteristics, cardiovascular risk factors and disease, and antidepressant use, we found significant inverse associations between moderate and high anxious depression (ref:low) with B-SEVLT learning and recall, DSS and GCS. Moderate, but not high, anxious depression was inversely associated with WF. Associations were not modified by sex, Hispanic heritage, or age. Conclusions: Increased anxious depression symptomatology is associated with decreased neurocognitive function among Hispanics. Longitudinal studies are needed to establish temporality and infer if negative emotional symptoms precede cognitive deficits.
Bibliographical noteFunding Information:
In this cross-sectional study, we found a significant inverse association of high and moderate anxious depression (ref: low anxious depression) class with neurocognitive function. To our knowledge, this is the first study to investigate the anxious depression construct and neurocognitive function among diverse middle-aged and older Hispanics. High independent levels of anxiety and depression symptoms have been reported to be associated with cognitive decline in the elderly. 5,31–34 One study 35 reported depressive symptoms as an early marker of cognitive change, although others have found no associations. 34,36–38 Our results emphasize how elevated combined anxious depression symptomatology is associated with poorer cognitive performance among diverse Hispanics. A recent review reported that depression states could be considered as risk factors for cognitive decline, although further work is needed to determine if depressive and related negative emotional states such as anxious depression represent a prodromal phase for cognitive decline. 39 A prospective epidemiological study among 1,094 participants found that, cross-sectionally, depressive symptoms were significantly associated with poor cognitive performance—although over a 12-year follow-up period, depressive symptoms were not significantly associated with cognitive decline. 40 Authors in this study tested similar cognitive domains as we did in our study but did not include measures of combined anxiety and depressive symptoms. Our study provides important preliminary results for a future longitudinal study to determine if ADS is associated with cognitive decline among this diverse cohort of middle-aged and elderly Hispanics. Although our results showed that individuals of Puerto Rican heritage had the highest inverse association between anxious depression and cognitive function, the statistical significance of the inverse association applies across all groups of Hispanics. All of the other inverse associations of moderate and high anxious-depression with cognition remained significant after controlling for demographics, income, education, antidepressants and cardiovascular risk factors such as diabetes and hypertension. These results emphasize how increased levels of anxious depression, which is common among Hispanics, affect neurocognitive functioning. 2,19,28 Word Fluency was the only domain that was not significantly associated with high ADS. In our previous HCHS/SOL neurocognitive report, decreased word fluency was found across Hispanic heritage except for those individuals from South American heritage after accounting for sociodemographics, cardiovascular covariates, and depression. 14 Our findings are consistent with a study by Fuji et al. that found no association of word fluency with anxiety and depressive symptoms. 41 How somatic and emotional symptoms affect semantic memory and fluency among Hispanics of different backgrounds remains to be further studied. Our results showed that the inverse association of high and moderate anxious depression with neurocognition is uniform among the different Hispanic heritage groups. How this association of ADS with neurocognition affects other ethnic groups remains to be studied. Additionally, sex and age did not modify the relationship between ADS and cognition. To our knowledge there are no studies examining the bidirectional association between anxious depression and neurocognitive function. Perrino et al. 42 conducted a longitudinal study to test the bidirectional association between neurocognition and depressive symptoms. Cross-sectionally, the authors found a significant association between depression and further development of cognitive decline but did not find a significant bidirectional association between depressive symptoms and cognitive decline over a 3-year period. 42 Our study is a preliminary report in that direction, considering that individuals with combined anxiety and depressive symptomatology face greater disability, are frequently undertreated, and have a greater proportion of chronic cardiometabolic diseases. 2,28 A previous study from HCHS/SOL indicated that there is an association between anxiety and depressive symptoms with cardiovascular risk factors. 43 Additionally, one study found that 43% of participants with cognitive decline had a comorbid cardiometabolic disease such as hypertension or diabetes. 44 Our study is the first to report an association of the commonly encountered anxious depression construct with poor neurocognitive function among diverse Hispanics independent of existing socioeconomic and cardiovascular risk factors. These findings have important public health implications because of the high prevalence of anxiety and depression symptoms and cardiovascular risk factors among Hispanics. The literature has described that symptoms of depression and cognitive decline are commonly encountered in clinical settings and are frequently untreated. 42,45 Further, a previous HCHS/SOL study found a significant association between high levels of anxiety and depression symptoms and under-treatment with antidepressants among participants with several cardiovascular risk factors. 28 In our analyses, we did control for antidepressants, even though only 9% of the target population reported taking antidepressants, and it has been reported that few Hispanics in this cohort and nationally have received antidepressant treatment. 28,46 Our results further suggest the importance of early identification and treatment of anxious depression in conjunction with cardiometabolic risk factors to reduce the burden associated with poor cognitive function and prevention of further cognitive decline. Clinical trials are needed to determine if early treatment with antidepressants affects the association of anxious depression and cognitive decline over time. Caution is warranted in interpreting our results, considering limitations associated with the sample, study methods, and design. First, the sample is not nationally representative of Hispanics living in the United States. Rather, it is representative of the Hispanic population residing in the four study sites. Second, the cross-sectional design of the study does not allow causal inferences. Third, structured clinical interviews were not used, therefore formal diagnoses were not made. Despite these limitations, the study has notable strengths including the large sample size, inclusion of Hispanic subjects from different heritage groups, and use of comprehensive battery of neurocognitive tests. Additionally, the measurement of the anxious depression construct used a latent class approach that minimizes measurement error. In conclusion, anxious depression symptomatology is common and significantly associated with poor cognitive function among Hispanics of diverse heritage, independent of socioeconomic background and cardiovascular risk factors. Additional research is needed to address treatment and interventions to reduce the burden associated with anxious-depression symptomatology and neurocognitive functioning. Drs. González and Tarraf receive support from the National Institute of Aging ( AG48642 ). Funded by The Hispanic Community Health Study/Study of Latinos , which was supported by contracts from the NHLBI to the University of North Carolina ( N01-HC65233 ), University of Miami ( N01-HC65234 ), Albert Einstein College of Medicine ( N01-HC65235 ), Northwestern University ( N01-HC65236 ), and San Diego State University ( N01-HC65237 ). Drs. Daviglus, Gallo, and Kaplan, also receive support from the National Institute of Aging ( AG48642 ).The following Institutes/Centers/Offices contribute to the HCHS/SOL through a transfer of funds to the NHLBI: National Center on Minority Health and Health Disparities, the National Institute of Deafness and Other Communications Disorders, the National Institute of Dental and Craniofacial Research, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute of Neurological Disorders and Stroke, and the Office of Dietary Supplements. Dr. Hernandez is funded by NHLBI through award 1K01HL130712-01A1 . The contents of this report are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. We thank the participants and staff of the HCHS/SOL for their important contributions. The authors have no reported conflict of interest. Special thanks to Alan Conceicao for the editorial support for this manuscript. Appendix
- Anxious depression